Approach Considerations

Initiating antibiotics early significantly reduces the mortality rate of Rocky Mountain spotted fever (RMSF) from 20% to approximately 5%. In addition, it prevents early complications. Patients may also require oxygen or intubation.
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Dehydration due to high fever and vomiting may occur. Appropriate and aggressive fluid management with isotonic fluids should be instituted. Monitor urine output and blood pressure. A Swan-Ganz catheter may be needed to monitor hemodynamics in some patients.

Pregnancy

Whether R rickettsii can cross the placenta and adversely affect the fetus remains unknown. In a case report, a pregnant patient with RMSF was treated with chloramphenicol successfully, with no apparent adverse maternal or neonatal effects.
[17]

Transfer

Proper personnel trained in complicated airway intervention and treatment of shock should be available to patients with RMSF who are comatose, convulsing, or hypotensive.

Outpatient care

Clinically mild cases may be treated on an outpatient basis. However, RMSF can progress rapidly. Because roughly 10% of outpatients subsequently required admission, close follow-up is necessary if outpatient management is planned.

Consultations

Always report tick-borne illnesses to public health authorities. Consultation with an infectious disease specialist is advised. A dermatologist should be consulted to obtain a skin biopsy specimen for immunofluorescent staining, if available.

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Prehospital and Emergency Department Care

In emergency prehospital care for Rocky Mountain spotted fever (RMSF), deliver supportive therapy, including airway support and intravenous (IV) fluids, as determined by the severity of the patient's condition. Emergency department care in RMSF includes early empiric therapy with doxycycline and hemodynamic support, as needed.

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Inpatient Care

Hospitalization was required in 72% of confirmed cases of Rocky Mountain spotted fever (RMSF) reported to the Centers for Disease Control and Prevention (CDC). Hospitalization, when required, usually occurs on the fourth day after symptom onset.

Admit moderately to severely ill patients to the hospital. Indications for admission may include altered mental status or other neurologic manifestations of RMSF, abdominal pain (may mimic an acute surgical abdomen), thrombocytopenia, or hypotension due to RMSF myocarditis. Admit severely ill patients to the intensive care unit (ICU).

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Ophthalmic Care

Supportive therapy according to the needs of individual patients is indicated. Moderate to severe uveitis may be treated with topical cycloplegics and corticosteroids, although no reliable information on efficacy is available. Artificial tears and ocular lubricating ointment may help to relieve discomfort from periorbital edema and petechial conjunctivitis.

Patients with Rocky Mountain spotted fever (RMSF) usually do not present initially to an ophthalmologist. Usually, these patients are already under the care of an internist or infectious disease physician.

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Prevention

Protective measures against tick bites include the following:

Avoid dogs with ticks and tick-infected areas

Use protective, light-colored clothing that covers arms and legs; tuck pants in socks to protect legs

Apply tick-repellent chemicals, such as diethyltoluamide (DEET, Autan) or permethrin, to pants and sleeves

Search the entire body every 3-4 hours when in an infested area; common areas of attachment are in scalp, pubic, or axillary hair

When a tick is present, it should be promptly removed using gentle, steady traction with tweezers. Care should be taken not to crush the tick or to leave any mouthparts. Hands should be protected with gloves.

Because the tick needs 6-10 hours of feeding to transmit the disease, early discovery and removal of ticks can prevent infection. Prophylaxis with doxycycline for 7 days is recommended after tick removal.

The patient's rash is a major diagnostic sign of Rocky Mountain spotted fever (RMSF). Image courtesy of the Centers for Disease Control and Prevention (CDC).

In the United States, the American dog tick (Dermacentor variabilis) is the most commonly identified source of transmission. This tick is actually found mainly east of the Rocky Mountains (distribution is shown). The Rocky Mountain wood tick (Dermacentor andersoni), found predominantly in the mountain states, can transmit RMSF and tularemia to humans. The brown dog tick (Rhipicephalus sanguineus) has recently been identified as a source of RMSF in the southwestern U.S. and along the U.S.-Mexico border, but it is found throughout the country and the world. Image courtesy of the Centers for Disease Control and Prevention (CDC).

Peter MC DeBlieux, MD Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center